Cancer – The Best Way to Die?

A blog post late last month by Richard Smith, former editor of the BMJ, has provoked a storm of criticism and controversy. Provocatively entitled, “Dying of Cancer is the Best Death”, the author argues that a death from cancer is preferable and closes, controversially, with:

“…let’s stop wasting billions trying to cure cancer, potentially leaving us to die a much more horrible death.”

To be fair, the points Smith attempted to make in his article have been taken to their emotional extreme by his critics – so much so that he has written a follow-up post better explaining his (far more moderate) views.

In any case, two questions come to mind. Might cancer indeed be the best, or least worst, death? And is it possible money allocated to cancer treatment and research could be better spent elsewhere? The first will be addressed in this piece – the latter, on the other hand, cannot be done justice in this given space (and may be the subject of a follow-up post).

Why, then, does Smith believe that cancer is, all things considered, a good way to die? He points out that everyone, at some point, must die – and that there are, excluding suicide and euthanasia, only “four ways to die”:

Sudden, presumably unexpected, death

The long, slow decline of dementia

The cyclical course of gradual organ failure

Cancer

A sudden death, he believes, while painless and short, leaves your loves ones unprepared, while the decline of dementia slowly erases your sense of self. Organ failure has its ups and down, and can lead to medical overtreatment and long hospital stays.

On the other hand, a death from cancer, he claims, means that you “may bang along for a long time but go down usually in weeks”, a “romantic view…but…achievable with love, morphine, and whisky.” That is, that a diagnosis of cancer allows you to be reasonably healthy for some time, before a quick decline, allowing you to tackle a bucket list before finally succumbing to your inevitable end.

It is precisely this view of a death from cancer that has drawn Smith immense criticism, with commentators noting that repeated cycles of chemotherapy, emotional and physical stress, and uncertainty about prognosis are also almost always unwanted components of this time.

More problematically, however, is that Smith’s “four ways to die” are arbitrary and blur together. Cancer is a heterogeneous beast, poorly captured as a single generic category. Some types, such as skin, breast, testicular and prostate cancers, have effective treatment regimes, and excellent odds for long-term survival or even a complete cure. Indeed, these can have better expected outcomes than certain chronic organ failure conditions, including Chronic Obstructive Pulmonary Disease, and Alcoholic Liver Disease. Even all-too-common heart failure has mortality rates approaching 30-40% in the first year. Others, however, like pancreatic, lung, and brain tumours, have all but resisted the march of modern medicine, and continue to have stubbornly poor prognoses even with intensive and radical treatment, ranging from weeks to months.

Despite these issues, however, there is a salvageable moral to be drawn from this story.

Everyone who is alive now will likely, at some point, have to die – barring a miraculous discovery which makes immortality plausible. If we had the ability to choose our death, many of us would ask for two things: that the actual decline be fast, and relatively pain-free; and that there be some time, before the event, to put our affairs in order and say our final goodbyes.

While both of these depends on factors largely beyond our control (barring the possibility of voluntary euthanasia), they are amenable, to a degree, to prior thought and planning – of having the important conversations with friends and family, making a will, and putting together advanced directives for end-of-life care.

In most cases, however, these discussions around the inevitable end fail to take place, despite evidence that it may improve end-of-life care and the experience of friends and family. There are a variety of reasons for this, including social taboos around death and lack of knowledge (see this). Yet nothing is quite as effective in cutting through these barriers to facing the reality of death as a diagnosis of the “Big C”. Indeed, even though many chronic medical conditions, as mentioned above, have less life expectancy and poorer prognoses than some cancers, they do not carry the same urgency and weight.

So perhaps while cancer is not necessarily the best death, by forcing us to seriously consider our mortality and act accordingly, it increases our chances of meeting these two ideals for a good death. But the need for discussions around death is not solely limited to the “Big C”, as previously mentioned. What we should focus on, then, is perhaps coming to terms with the idea of eventual death and dying; and ensuring that sensible and timely conversations can take place, without the need for the panic of a cancer diagnosis.

Arguably, then, what makes a good death is one that is planned, and accepted – cancer or otherwise.